Provider Demographics
NPI:1528001328
Name:SWENSEN, SWEN RUSSEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SWEN
Middle Name:RUSSEL
Last Name:SWENSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 10TH AVE
Mailing Address - Street 2:#224
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2853
Mailing Address - Country:US
Mailing Address - Phone:801-408-7660
Mailing Address - Fax:
Practice Address - Street 1:324 10TH AVE
Practice Address - Street 2:#224
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2853
Practice Address - Country:US
Practice Address - Phone:801-408-7660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1565671205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057029Medicaid
UT006902802Medicare PIN
UT000057736Medicare PIN
UT005773601Medicare PIN
UT006994012Medicare PIN
UTD99960Medicare UPIN
UT005502005Medicare PIN
UT942854057029Medicaid
000061544Medicare PIN